Author
Topic: What comes after the ACA? (Read 722566 times)

I think the fact that we have a lot of established infrastructure makes it appear that it doesn't cost much to deliver water or electricity. In fact an incredible amount of investment went into setting up power distribution lines, laying pipes underground, and maintaining all of that. You have to amortize that cost over time to do a fairer comparison since healthcare has more on-going costs by its nature.

I'm not saying it doesn't cost money to have utilities, I'm saying it's no where near 20% of GDP.

I think the fact that we have a lot of established infrastructure makes it appear that it doesn't cost much to deliver water or electricity. In fact an incredible amount of investment went into setting up power distribution lines, laying pipes underground, and maintaining all of that. You have to amortize that cost over time to do a fairer comparison since healthcare has more on-going costs by its nature.

Exactly...building new infrastructure is extremely expensive. Here in SE Minnesota a new high voltage distribution system was built to serve the growing wind power generation in the area. It was a massive undertaking..and is only a small part of a larger project :

I think the fact that we have a lot of established infrastructure makes it appear that it doesn't cost much to deliver water or electricity. In fact an incredible amount of investment went into setting up power distribution lines, laying pipes underground, and maintaining all of that. You have to amortize that cost over time to do a fairer comparison since healthcare has more on-going costs by its nature.

^This^

We're struggling with that right now, because our water infrastructure needs massive updates, and we're having storm water runoff problems. Nobody wants to pay for it, but the helpful (unelected) folks at the Northeast Ohio Regional Sewer District are more than willing to tack on some extra fees for (maybe) starting to address some of the problems in a few of the communities that matter more than the others.

I know this is a tangent but does anyone ever think that prevailing wage, minority/women business, endless regulations, idiotic bio-diesel/alternative energy mandates have anything to do with the cost? Oh and that the government (people with no incentive to efficiently produce and permanent job security) is managing the project?

Oh and that the government (people with no incentive to efficiently produce and permanent job security) is managing the project?

Not only are you ignorant, you're offensive while you're at it. You can just shut the hell up right now, because you have no idea what you're talking about.

I will not stand around and let idiots with no grasp of reality repeatedly malign me and my family with such unfounded accusations. Please consider that these are real people you're insulting, and many of us are right here.

I'm a federal employee. My wife is a federal employee. If you want to continue insulting my wife, I suggest you come stand in my living room and do it in person instead of through my home computer screen.

Uhm, back in reality it just doesn't cost a lot to deliver water, or electricity. Please let me know what other markets are functional under price controls. Rent control being the classic example of stupid policies for political reasons.

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See above posters' refutation of this statement.

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You don't seem to understand basic economics, that there is a limit to what people will pay, and that's why doctors can't/don't charge $100,000 per office visit right?

I understand basic economics perfectly well. There is a limit to what people will pay when (1) their lives don't depend on the product they are buying, and (2) they have a reasonable opportunity to choose a less expensive alternative. Neither of those apply to health care. People will use life-saving care regardless of the cost and regardless of their ability to pay. In fact, the law forbids providers from barring access to that care, regardless of ability to pay. Those who can pay get stuck paying for those who can't. They have no way to opt out of that, and they are powerless to stop the ever-increasing prices.

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Prices come from what is paid, and right now the government is spending unlimited amounts for old people's healthcare with tax dollars, making all those not on the dole heading straight for a cliff. It's not just the prices the government paid, it's also paying for unnecessary, extra care that much is completely preventable but there's not enough incentive for the patient to conduct.

Prices come from what the market will bear, and as I said, the market will bear a lot when people's lives depend on the product and they don't have less expensive alternatives.

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Guess it will only change when the middle class thinks they've had enough, and 20% of GDP isn't that value. Will it get to 30%? 40%? Who knows...

The middle class had enough a long, long time ago, but that didn't stop the never-ending upward price spiral. The health industry has us over a barrel, and the only thing we can do about it is elect politicians who will stop the price gouging.

and 20% of GDP isn't that value. Will it get to 30%? 40%? Who knows...

One of the features of the ACA was to provide research on what medical procedures were efficacious. It turns out lots of beliefs about medicine that doctors held dearly didn't stand up to research and scrutiny. Patients were getting way too many procedures done because doctors and hospitals make money by doing more, not by providing the best patient outcome. The ACA was an effort to change the motives toward better patient care and the net result of that provided an avenue for containing health care costs. Research found that a small percentage of patients were responsible for a majority of medical care consumption - and by encouraging these patients to better follow their prescribed medical care led to less use as the patients improved. Ending research to find better medical practices will just end up driving health care costs even higher.

I know this is a tangent but does anyone ever think that prevailing wage, minority/women business, endless regulations, idiotic bio-diesel/alternative energy mandates have anything to do with the cost? Oh and that the government (people with no incentive to efficiently produce and permanent job security) is managing the project?

Mega tangent. Don't confuse people's lack of willingness to argue against your points as you winning some sort of victory.

Oh and that the government (people with no incentive to efficiently produce and permanent job security) is managing the project?

Not only are you ignorant, you're offensive while you're at it. You can just shut the hell up right now, because you have no idea what you're talking about.

I will not stand around and let idiots with no grasp of reality repeatedly malign me and my family with such unfounded accusations. Please consider that these are real people you're insulting, and many of us are right here.

I'm a federal employee. My wife is a federal employee. If you want to continue insulting my wife, I suggest you come stand in my living room and do it in person instead of through my home computer screen.

Right after you apologize to the 100,000,000+ conservatives you've insulted in this topic Sol.

I honestly hope you're one of the good ones, more than a few bad apples in the bunch.

Ah, ok, that makes sense. So the US would need more services for poor areas and more focus on certain ailments, like diabetes, in certain areas.

I think you're misunderstanding.

When conservatives say "universal health care can't work in America because America is too big and diverse" they aren't saying that we need to address the issue of unequal access to care, they are saying that we have too many poor and black people who need care and they don't want rich and white people to pay for that.

It's not a call to action, which is how you seem to have interpreted it. It's not a plan to make things better. It's just another reason to say "diversity is bad, we should be a more homogenous country" and "black people are bad, we can't have nice things anymore because we've given up on white superiority". It's only thinly veiled racism. You can stop giving them the benefit of the doubt on this one.

How's that citation? You calling all conservatives racist. Forgot so soon?

Aetna had previously expressed concerns about the uncertainties created by Republicans’ push to repeal and replace Obamacare. The insurer late last month warned that the individual insurance market is deteriorating and that it planned to shed most of that business.

Humana is out. Looks like Aetna will be out. There's going to be more.

Trump's reaction: "Obamacare continues to fail. Humana to pull out in 2018. Will repeal, replace & save healthcare for ALL Americans."

OK. I can't help but be a tad skeptical until you actually show us something.

Aetna had previously expressed concerns about the uncertainties created by Republicans’ push to repeal and replace Obamacare. The insurer late last month warned that the individual insurance market is deteriorating and that it planned to shed most of that business.

Humana is out. Looks like Aetna will be out. There's going to be more.

Trump's reaction: "Obamacare continues to fail. Humana to pull out in 2018. Will repeal, replace & save healthcare for ALL Americans."

OK. I can't help but be a tad skeptical until you actually show us something.

As the leak from the Philly conclave showed, this is a deliberate scorched-earth strategy. Kick as many legs out from under the ACA as possible, watch it collapse, and say, "see, I told you it was collapsing." Then blame the Democrats for their "failed" Obamacare law, and bask in the glory of re-election in the 2018 mid-terms. At that point, they can pursue their real dream of putting the health care system back to the way it was pre-ACA. They have no real intention of maintaining the coverage gains or providing universal access. They just want political cover for screwing everyone who gained coverage under the ACA.

I know this is a tangent but does anyone ever think that prevailing wage, minority/women business, endless regulations, idiotic bio-diesel/alternative energy mandates have anything to do with the cost? Oh and that the government (people with no incentive to efficiently produce and permanent job security) is managing the project?

Not only are you ignorant, you're offensive while you're at it. You can just shut the hell up right now, because you have no idea what you're talking about.

I will not stand around and let idiots with no grasp of reality repeatedly malign me and my family with such unfounded accusations. Please consider that these are real people you're insulting, and many of us are right here.

I'm a federal employee. My wife is a federal employee. If you want to continue insulting my wife, I suggest you come stand in my living room and do it in person instead of through my home computer screen.

Right after you apologize to the 100,000,000+ conservatives you've insulted in this topic Sol.

I honestly hope you're one of the good ones, more than a few bad apples in the bunch.

It isn't just Sol that you are insulting with your unfounded rhetoric. I am requesting that you stop it.For the record, I do not trust for-profit companies to do what is in citizens' best interests more than federal workers. It is also untrue that federal workers have permanent job security; in general it is on par with most unionized private sector jobs.

I honestly hope you're one of the good ones, more than a few bad apples in the bunch.

You are complaining the sol called you a racist (which you inferred rather than producing evidence of it), then you follow it up with the incindiery language "one of the good ones" ??

You'd better get your head on straight dude. If you ever use that phrase in front of anyone other than a white male conservative you are likely to get the shit beat out of you. I'm going to assume you only know white male conservatives and that's why no one has ever told you before that's unacceptable language

and 20% of GDP isn't that value. Will it get to 30%? 40%? Who knows...

One of the features of the ACA was to provide research on what medical procedures were efficacious. It turns out lots of beliefs about medicine that doctors held dearly didn't stand up to research and scrutiny. Patients were getting way too many procedures done because doctors and hospitals make money by doing more, not by providing the best patient outcome. The ACA was an effort to change the motives toward better patient care and the net result of that provided an avenue for containing health care costs. Research found that a small percentage of patients were responsible for a majority of medical care consumption - and by encouraging these patients to better follow their prescribed medical care led to less use as the patients improved. Ending research to find better medical practices will just end up driving health care costs even higher.

Here's my problem with the whole health care debate (and really health car in general) - how do we know how much medical procedure "x" should cost? Without some semblance of a free market (e.g. one where consumers know ahead of time how much the procedure will cost and have some motive to keep the cost down), no one can really say what a certain procedure should cost. Maybe consumers are willing to pay more than the government thinks for some things, and less for others. Who knows?

Yes, CDP45, please kindly shut the hell up about how lazy my federally employed husband is. Especially given that in addition to his current job as a scientist, he also served in the military and as a border patrol agent.

Here's my problem with the whole health care debate (and really health car in general) - how do we know how much medical procedure "x" should cost? Without some semblance of a free market (e.g. one where consumers know ahead of time how much the procedure will cost and have some motive to keep the cost down), no one can really say what a certain procedure should cost. Maybe consumers are willing to pay more than the government thinks for some things, and less for others. Who knows?

You bring up a valid point that customers in general have no real understanding what various medical treatments actually cost.However, I'd argue that 'free-market' (i.e. private insurance) forces have intentionally kept people in the dark about medical costs for at least the last several decades. Ask somehow how much a doctor's visit is and he/she might respond "$40" (their co-pay). But that's not what the visit actually costs. Approximately zero people with private insurance could tell you the cheapest doctor/clinic to go to. At best he/she could just say who was "in-network". Typically when a patient has something done their "bill" list only their co-pay (if anything) and almost never what each procedure costs.

This is true for all procedures. Hopefully a person understands which doctors are within network, but one almost never knows where the cheapest place for X-rays is. Furthering this is that the reimbursement price for insurance companies is never the billed price, and different insurers put pressure to get the lowest reimbursement prices. So the invoiced cost is never the actual cost. Medicare, for example, has thousands of procedural codes and a set rate for each one, regarless of where it's done.

I would support measures to ensure equality among procedures and the total cost clearly printed on a customer's invoice (whether they paid out of pocket or not).It gets to be a mess, though, because some places have higher rents, newer equipment or better/more staff, all of which has to be paid for somehow.

Here's my problem with the whole health care debate (and really health car in general) - how do we know how much medical procedure "x" should cost? Without some semblance of a free market (e.g. one where consumers know ahead of time how much the procedure will cost and have some motive to keep the cost down), no one can really say what a certain procedure should cost. Maybe consumers are willing to pay more than the government thinks for some things, and less for others. Who knows?

You bring up a valid point that customers in general have no real understanding what various medical treatments actually cost.However, I'd argue that 'free-market' (i.e. private insurance) forces have intentionally kept people in the dark about medical costs for at least the last several decades. Ask somehow how much a doctor's visit is and he/she might respond "$40" (their co-pay). But that's not what the visit actually costs. Approximately zero people with private insurance could tell you the cheapest doctor/clinic to go to. At best he/she could just say who was "in-network". Typically when a patient has something done their "bill" list only their co-pay (if anything) and almost never what each procedure costs.

This is true for all procedures. Hopefully a person understands which doctors are within network, but one almost never knows where the cheapest place for X-rays is. Furthering this is that the reimbursement price for insurance companies is never the billed price, and different insurers put pressure to get the lowest reimbursement prices. So the invoiced cost is never the actual cost. Medicare, for example, has thousands of procedural codes and a set rate for each one, regarless of where it's done.

I would support measures to ensure equality among procedures and the total cost clearly printed on a customer's invoice (whether they paid out of pocket or not).It gets to be a mess, though, because some places have higher rents, newer equipment or better/more staff, all of which has to be paid for somehow.

I totally agree with that. Especially the part in bold above. I don't consider insurance to be anything close to a true free market. Like most, I don't have a clue how much it would cost me to go in for a check-up or physical if I didn't have insurance. There's absolutely no incentive for me to shop around for a good price. My cost is going to be the same $40 co-pay wherever I go. That's about as far from how a market economy is supposed to operate as you can get.

I honestly hope you're one of the good ones, more than a few bad apples in the bunch.

You are complaining the sol called you a racist (which you inferred rather than producing evidence of it), then you follow it up with the incindiery language "one of the good ones" ??

You'd better get your head on straight dude. If you ever use that phrase in front of anyone other than a white male conservative you are likely to get the shit beat out of you. I'm going to assume you only know white male conservatives and that's why no one has ever told you before that's unacceptable language

No, I'm showing evidence of Sol insulting 100,000,000+ Americans (I'm not a conservative) at a personal level, where I'm insulting the incentive structure and cost overruns of government projects.

Interesting how that personal insult can fly and no one says anything...guess this is a one-way forum...but that seems intolerant and hypocritical.

I have no idea what one of the good ones means other than how I used it for saying there's a lot of bad apples, but I do get your veiled threat of violence, good job internet tough guy!

Okay, I was taken in. I swallowed the troll line completely, momentarily suspending by disbelief. That was stupid.

CDP45 isn't a conservative. He/she doesn't actually believe any of the things posted here. Participation was only for personal entertainment value, because it's fun to get people riled up. I understand that some people who feel insecure and powerless in their own lives often resort to this story of behavior as a form of self soothing therapy. It's the same reason sexual assault victims so often turn to sexual assault.

CDP45, you have entertained us all at my expense but now we are done. I will not engage with any more such silly shenanigans with you in the future. Your expressed views are not genuine or helpful or constructive. You are a blight on the forum and should find someplace else to harass until you find the peace you deserve.

I will continue to call you a troll and a liar if necessary, but I'll try not to let your personal attacks on me and my family hit home. The only thing you seek here is conflict and agitation, so I am hopeful that depriving you off those will incentive you to move along to some other forum. You are not welcome here if you can't be constructive.

I don't consider insurance to be anything close to a true free market. Like most, I don't have a clue how much it would cost me to go in for a check-up or physical if I didn't have insurance. There's absolutely no incentive for me to shop around for a good price.

But it's the providers driving the pricing opacity, not the consumers. Right?

I would guess it's partly the insurance companies and partly the health care providers.

I will continue to call you a troll and a liar if necessary, but I'll try not to let your personal attacks on me and my family hit home. The only thing you seek here is conflict and agitation, so I am hopeful that depriving you off those will incentive you to move along to some other forum. You are not welcome here if you can't be constructive.

Here's my problem with the whole health care debate (and really health car in general) - how do we know how much medical procedure "x" should cost? Without some semblance of a free market (e.g. one where consumers know ahead of time how much the procedure will cost and have some motive to keep the cost down), no one can really say what a certain procedure should cost. Maybe consumers are willing to pay more than the government thinks for some things, and less for others. Who knows?

You bring up a valid point that customers in general have no real understanding what various medical treatments actually cost.However, I'd argue that 'free-market' (i.e. private insurance) forces have intentionally kept people in the dark about medical costs for at least the last several decades. Ask somehow how much a doctor's visit is and he/she might respond "$40" (their co-pay). But that's not what the visit actually costs. Approximately zero people with private insurance could tell you the cheapest doctor/clinic to go to. At best he/she could just say who was "in-network". Typically when a patient has something done their "bill" list only their co-pay (if anything) and almost never what each procedure costs.

This is true for all procedures. Hopefully a person understands which doctors are within network, but one almost never knows where the cheapest place for X-rays is. Furthering this is that the reimbursement price for insurance companies is never the billed price, and different insurers put pressure to get the lowest reimbursement prices. So the invoiced cost is never the actual cost. Medicare, for example, has thousands of procedural codes and a set rate for each one, regarless of where it's done.

I would support measures to ensure equality among procedures and the total cost clearly printed on a customer's invoice (whether they paid out of pocket or not).It gets to be a mess, though, because some places have higher rents, newer equipment or better/more staff, all of which has to be paid for somehow.

I totally agree with that. Especially the part in bold above. I don't consider insurance to be anything close to a true free market. Like most, I don't have a clue how much it would cost me to go in for a check-up or physical if I didn't have insurance. There's absolutely no incentive for me to shop around for a good price. My cost is going to be the same $40 co-pay wherever I go. That's about as far from how a market economy is supposed to operate as you can get.

While I agree with the senitment that there's no incentive for you (or anyone) to shop around for the best price on health care, I don't think health care can be treated the same as other consumables. Unpredictable as health emergencies are and far apart as many health care providers are (particularly in rural areas) we often don't have the option of choice, and choice is what drives free-market economies.

That's why I support regulation over free-market for health insurance.

Diving into this discussion without reading every comment, but IMO (and of course not just I but many others, including all the major modernized governments in the world), health care should not be a for-profit business. Naturally, providers and researchers should be compensated sufficiently, but there should be no health care and drug companies selling shares and seeking benefits through politics at the expense of the citizens of this country. Insurance companies should have much less involvement, if any, in patient care. Health care is a public, not private, issue. If the ACA had been implemented as was originally intended, it would have had far fewer problems, but it was hamstrung from the beginning for political reasons.

I know this is a tangent but does anyone ever think that prevailing wage, minority/women business, endless regulations, idiotic bio-diesel/alternative energy mandates have anything to do with the cost?

Women are a minority now? Or do you believe women are not entitled to equal opportunity or equal pay for equal work?

Do you also believe we should continue to burn coal and fossil fuels (the cost of which does not include the adverse respiratory health impacts the Obamacare has to pay for), or continue to frack your water supply so that the water you draw poisons you and your children? Is it not a worthy goal to find and fund alternative sources of energy that don't incur these negative externality costs?

Shorten the open enrollment window from 90 to 45 days starting in 2018.Require 100% verification of special enrollment periods with a much more limited interpretation of what it means.Consider past debts owed to insurer when it comes to the guaranteed availability requirement.Change the actuarial values of the metal plans from set values to within a range. Meaning your plan pays for less coverage. Example 90% gold becomes 92% to 86% av. The law doesn't permit this but they will try to get away with it. Interestingly the Silver with cost sharing reductions are being left alone at 73%, 87%, and 94% av.

The IRS will no longer reject tax returns that have blank check box for whether you have health insurance. This will weaken the enforcement of the individual mandate and push up rates as people refuse to buy insurance and face no consequence for it.

The people who loose the most are those who make too much to get any subsidies. The premiums will rise for them. Those who get subsidies should be somewhat protected.

Oh and that the government (people with no incentive to efficiently produce and permanent job security) is managing the project?

Not only are you ignorant, you're offensive while you're at it. You can just shut the hell up right now, because you have no idea what you're talking about.

I will not stand around and let idiots with no grasp of reality repeatedly malign me and my family with such unfounded accusations. Please consider that these are real people you're insulting, and many of us are right here.

I'm a federal employee. My wife is a federal employee. If you want to continue insulting my wife, I suggest you come stand in my living room and do it in person instead of through my home computer screen.

Coming from a guy who referred to vetrans as

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...every D student from backwoods Kentucky deserves a free college education and a lifetime of government welfare checks just because he signs up to cook powered eggs for a carrier group. The military needs to evolve...

Shorten the open enrollment window from 90 to 45 days starting in 2018.Require 100% verification of special enrollment periods with a much more limited interpretation of what it means.Consider past debts owed to insurer when it comes to the guaranteed availability requirement.Change the actuarial values of the metal plans from set values to within a range. Meaning your plan pays for less coverage. Example 90% gold becomes 92% to 86% av. The law doesn't permit this but they will try to get away with it. Interestingly the Silver with cost sharing reductions are being left alone at 73%, 87%, and 94% av.

The IRS will no longer reject tax returns that have blank check box for whether you have health insurance. This will weaken the enforcement of the individual mandate and push up rates as people refuse to buy insurance and face no consequence for it.

The people who loose the most are those who make too much to get any subsidies. The premiums will rise for them. Those who get subsidies should be somewhat protected.

Isn't that the point? Premiums rose last year at double digit rates - someone needs to pay for them. As long as insurance is a component of healthcare in the USA, this is probably what we can expect.

Shorten the open enrollment window from 90 to 45 days starting in 2018.Require 100% verification of special enrollment periods with a much more limited interpretation of what it means.Consider past debts owed to insurer when it comes to the guaranteed availability requirement.Change the actuarial values of the metal plans from set values to within a range. Meaning your plan pays for less coverage. Example 90% gold becomes 92% to 86% av. The law doesn't permit this but they will try to get away with it. Interestingly the Silver with cost sharing reductions are being left alone at 73%, 87%, and 94% av.

The IRS will no longer reject tax returns that have blank check box for whether you have health insurance. This will weaken the enforcement of the individual mandate and push up rates as people refuse to buy insurance and face no consequence for it.

The people who loose the most are those who make too much to get any subsidies. The premiums will rise for them. Those who get subsidies should be somewhat protected.

I like that it's a "stabilization" plan. Yes, let's stabilize it by letting all the healthy folks opt out. That's sure to work.

I did nothing of the sort. I spent that whole post praising existing veterans and supporting their benefits, and then suggested that in the future new recruits should receive fewer benefits, because there should be fewer of them.

But I'm not surprised that you would quote me so horribly out of context. I no longer expect anything more from you.

Frankly, large parts of the forum have been kind of disappointing lately. I miss the early days of the forum, when civil discourse was the norm instead of the exception and the population of members was slightly more willing to listen instead of just talk.

I did nothing of the sort. I spent that whole post praising existing veterans and supporting their benefits, and then suggested that in the future new recruits should receive fewer benefits, because there should be fewer of them.

But I'm not surprised that you would quote me so horribly out of context. I no longer expect anything more from you.

Frankly, large parts of the forum have been kind of disappointing lately. I miss the early days of the forum, when civil discourse was the norm instead of the exception and the population of members was slightly more willing to listen instead of just talk.

I'm sorry that you find it disappointing that this forum has progressed and that new ideas and broader points of view are being expressed.

I'm sorry that you find it disappointing that this forum has progressed and that new ideas and broader points of view are being expressed.

Is that what I just said? Thank you for proving my point by "quoting" me not only out of context, but incorrectly.

If you think the forum is "progressing" as it ages then you have a very different experience than I do. I think it is regressing to resemble most of the rest of the internet, instead. It's only a matter of time before half of the post here are "First!" and "Yay!"

I'm sorry that you find it disappointing that this forum has progressed and that new ideas and broader points of view are being expressed.

Is that what I just said? Thank you for proving my point by "quoting" me not only out of context, but incorrectly.

If you think the forum is "progressing" as it ages then you have a very different experience than I do. I think it is regressing to resemble most of the rest of the internet, instead. It's only a matter of time before half of the post here are "First!" and "Yay!"

It is quite apparent that we have different experiences. Nothing wrong with that!

Here's my problem with the whole health care debate (and really health car in general) - how do we know how much medical procedure "x" should cost? Without some semblance of a free market (e.g. one where consumers know ahead of time how much the procedure will cost and have some motive to keep the cost down), no one can really say what a certain procedure should cost. Maybe consumers are willing to pay more than the government thinks for some things, and less for others. Who knows?

You bring up a valid point that customers in general have no real understanding what various medical treatments actually cost.However, I'd argue that 'free-market' (i.e. private insurance) forces have intentionally kept people in the dark about medical costs for at least the last several decades. Ask somehow how much a doctor's visit is and he/she might respond "$40" (their co-pay). But that's not what the visit actually costs. Approximately zero people with private insurance could tell you the cheapest doctor/clinic to go to. At best he/she could just say who was "in-network". Typically when a patient has something done their "bill" list only their co-pay (if anything) and almost never what each procedure costs.

This is true for all procedures. Hopefully a person understands which doctors are within network, but one almost never knows where the cheapest place for X-rays is. Furthering this is that the reimbursement price for insurance companies is never the billed price, and different insurers put pressure to get the lowest reimbursement prices. So the invoiced cost is never the actual cost. Medicare, for example, has thousands of procedural codes and a set rate for each one, regarless of where it's done.

I would support measures to ensure equality among procedures and the total cost clearly printed on a customer's invoice (whether they paid out of pocket or not).It gets to be a mess, though, because some places have higher rents, newer equipment or better/more staff, all of which has to be paid for somehow.

You hit two important points here.

Medicare is the model for how cost control could be implemented. They simply tell the provider, "this is how much we're going to pay for procedure x." But unfortunately, providers have access to a huge market of patients who aren't covered by Medicare, so they can simply choose not to take Medicare patients, which limits how much downward pressure Medicare can put on overall prices. That's why "Medicare for all" (i.e., single payer) proposals have such appeal - they take away the provider's gouging power by moving all the powerless consumers into one large negotiating block.

But as you pointed out, not all providers experience the same costs, so a one-size-fits all price is likely to drive some providers out of business and result in reduced choices and access to care, particularly in thinly served rural markets. Here's where a utility-like approach could work. Use a regulatory commission to set prices according to geographic area. Providers could petition the commission for rate increases when they are experiencing losses (or not enough profit), and the commission could consider things like executive salaries, shareholder profits, and the providers' proclivity to add unneeded (but lucrative) capacity when deciding whether to grant the rate increases.

If you think the forum is "progressing" as it ages then you have a very different experience than I do. I think it is regressing to resemble most of the rest of the internet, instead. It's only a matter of time before half of the post here are "First!" and "Yay!"

This exactly!! That's why I spend less time here. It used to be a community and now it's just like every other large forum. I think that's bound to happen with anything that gets so large that the sense of community is gone. It's too bad but not unexpected.

Shorten the open enrollment window from 90 to 45 days starting in 2018.Require 100% verification of special enrollment periods with a much more limited interpretation of what it means.Consider past debts owed to insurer when it comes to the guaranteed availability requirement.Change the actuarial values of the metal plans from set values to within a range. Meaning your plan pays for less coverage. Example 90% gold becomes 92% to 86% av. The law doesn't permit this but they will try to get away with it. Interestingly the Silver with cost sharing reductions are being left alone at 73%, 87%, and 94% av.

The IRS will no longer reject tax returns that have blank check box for whether you have health insurance. This will weaken the enforcement of the individual mandate and push up rates as people refuse to buy insurance and face no consequence for it.

The people who loose the most are those who make too much to get any subsidies. The premiums will rise for them. Those who get subsidies should be somewhat protected.

I like that it's a "stabilization" plan. Yes, let's stabilize it by letting all the healthy folks opt out. That's sure to work.

Let's be real, folks. What comes after the ACA is... nothing.

-W

The Republican spin machine is quiet something to behold. They claim the ACA is out of control and needs to be "stabilized". They then make proposals designed to destabilize it while claiming the opposite. The biggest thing destabilizing the insurance markets are the constant threats of the government (the Rebublicans) walking away from funding of the law.

These are tinkering changes around the edges. As long as they don't have 60 Senate votes the law is going no where. They will declare victory with minor changes and go home. They will tell people how they fixed everything and their base will eat it up. The base is smart enough to figure it out. Alternate facts has become reality.

Now that the Republicans seem to be floundering in their efforts to offer an ACA alternative, I am almost hoping that we just see everything crash and burn to the point that whoever comes next gets a clear mandate for single payer. (Not really because people will die and go bankrupt.) Personally, I'd like to see single payer in a few states first so that people get a certain comfort level with it (a la Marijuana legalization).

Sometimes I wonder if this was really Obama's long game. Even if the ACA is entirely gutted or repealed, the expectation has gone from "Should the government be involved in health care at all?" to "How can the government help me get health care?". When premiums go up due to insurer uncertainty, lifetime limits get reinstated, people start getting rejected for preexisting conditions, who is going to get the blame for that? The people that currently hold all three branches of government.

Here's my problem with the whole health care debate (and really health car in general) - how do we know how much medical procedure "x" should cost? Without some semblance of a free market (e.g. one where consumers know ahead of time how much the procedure will cost and have some motive to keep the cost down), no one can really say what a certain procedure should cost. Maybe consumers are willing to pay more than the government thinks for some things, and less for others. Who knows?

You bring up a valid point that customers in general have no real understanding what various medical treatments actually cost.However, I'd argue that 'free-market' (i.e. private insurance) forces have intentionally kept people in the dark about medical costs for at least the last several decades. Ask somehow how much a doctor's visit is and he/she might respond "$40" (their co-pay). But that's not what the visit actually costs. Approximately zero people with private insurance could tell you the cheapest doctor/clinic to go to. At best he/she could just say who was "in-network". Typically when a patient has something done their "bill" list only their co-pay (if anything) and almost never what each procedure costs.

This is true for all procedures. Hopefully a person understands which doctors are within network, but one almost never knows where the cheapest place for X-rays is. Furthering this is that the reimbursement price for insurance companies is never the billed price, and different insurers put pressure to get the lowest reimbursement prices. So the invoiced cost is never the actual cost. Medicare, for example, has thousands of procedural codes and a set rate for each one, regarless of where it's done.

I would support measures to ensure equality among procedures and the total cost clearly printed on a customer's invoice (whether they paid out of pocket or not).It gets to be a mess, though, because some places have higher rents, newer equipment or better/more staff, all of which has to be paid for somehow.

I totally agree with that. Especially the part in bold above. I don't consider insurance to be anything close to a true free market. Like most, I don't have a clue how much it would cost me to go in for a check-up or physical if I didn't have insurance. There's absolutely no incentive for me to shop around for a good price. My cost is going to be the same $40 co-pay wherever I go. That's about as far from how a market economy is supposed to operate as you can get.

This is exactly the type of thing I was talking about:

“What if 30 percent of the public had Health Savings Accounts?” said Paul. “What do you do when you use your own money? You call up doctors and ask the price… if you create a real marketplace, you drive prices down.”

“What if 30 percent of the public had Health Savings Accounts?” said Paul. “What do you do when you use your own money? You call up doctors and ask the price… if you create a real marketplace, you drive prices down.”

Haha, yeah, I'm having a heart attack right now -- better get on the phone and shop prices! :)

Oh no wait, even better, let's be proactive and shop stent prices BEFORE I have a heart attack, even though I appear to be in perfectly good condition. "Hello, yes, I would like to know the price of a stent, and also the cost to implement it. What's that you say? There are a ton of factors that could affect the final cost other than just the hardware cost of the stent?"

Exactly. Free market forces are only effective when the consumer has ample choiceHealth care (different from health insurance) inherently cannot provide choice for two reasons:1) people cannot 'shop around' for the services they need since i) it's often urgent and ii) you typically need to see a doctor before knowing what health care you need (customers cannot comparison shop)

2) In large swaths of rural US there is only one option for many health care proceedures. Unlike cups of coffee there aren't 40 different vendors selling reconstructive knee surgery within a 15 mile radius.

“What if 30 percent of the public had Health Savings Accounts?” said Paul. “What do you do when you use your own money? You call up doctors and ask the price… if you create a real marketplace, you drive prices down.”

Haha, yeah, I'm having a heart attack right now -- better get on the phone and shop prices! :)

Oh no wait, even better, let's be proactive and shop stent prices BEFORE I have a heart attack, even though I appear to be in perfectly good condition. "Hello, yes, I would like to know the price of a stent, and also the cost to implement it. What's that you say? There are a ton of factors that could affect the final cost other than just the hardware cost of the stent?"

Exactly. Free market forces are only effective when the consumer has ample choiceHealth care (different from health insurance) inherently cannot provide choice for two reasons:1) people cannot 'shop around' for the services they need since i) it's often urgent and ii) you typically need to see a doctor before knowing what health care you need (customers cannot comparison shop)

2) In large swaths of rural US there is only one option for many health care proceedures. Unlike cups of coffee there aren't 40 different vendors selling reconstructive knee surgery within a 15 mile radius.

I disagree that it's often urgent. How many times have you been to a doctor's office or hospital in your life? Of those times, how many were truly urgent? Personally, I've only had one instance when I needed medical attention right away. I could have shopped around all the other times. Even the one time when it was urgent, I might have driven a bit further if I'd known I could get a better deal somewhere else.

If you think the forum is "progressing" as it ages then you have a very different experience than I do. I think it is regressing to resemble most of the rest of the internet, instead. It's only a matter of time before half of the post here are "First!" and "Yay!"

This exactly!! That's why I spend less time here. It used to be a community and now it's just like every other large forum. I think that's bound to happen with anything that gets so large that the sense of community is gone. It's too bad but not unexpected.

To tie this into the topic at hand, both the forum and the individual health care market are susceptible to loosely analogous self-reinforcing death spirals. In both cases, a decline in the share of "healthy" participants will itself contribute to further declines. Your (understandable) decision to curtail your participation here in response to the forum's decline in quality has the unfortunate effect of amplifying that same decline in quality.

In the case of the individual health care market, the CMS/HHS proposed ACA rule changes actually would have the net effect of improving the market's risk pool, bolstering the incentive for insurers to participate in ACA exchanges. However, as Jim noted above, this would-be stabilization effect is dramatically outweighed by the destabilization effects already caused by the Republican-fueled lack of certainty as to the future of the regulatory regime for the individual health insurance market, not to mention the destabilization effects that would result from the IRS's failure to enforce the individual mandate.

“What if 30 percent of the public had Health Savings Accounts?” said Paul. “What do you do when you use your own money? You call up doctors and ask the price… if you create a real marketplace, you drive prices down.”

Haha, yeah, I'm having a heart attack right now -- better get on the phone and shop prices! :)

Oh no wait, even better, let's be proactive and shop stent prices BEFORE I have a heart attack, even though I appear to be in perfectly good condition. "Hello, yes, I would like to know the price of a stent, and also the cost to implement it. What's that you say? There are a ton of factors that could affect the final cost other than just the hardware cost of the stent?"

Exactly. Free market forces are only effective when the consumer has ample choiceHealth care (different from health insurance) inherently cannot provide choice for two reasons:1) people cannot 'shop around' for the services they need since i) it's often urgent and ii) you typically need to see a doctor before knowing what health care you need (customers cannot comparison shop)

2) In large swaths of rural US there is only one option for many health care proceedures. Unlike cups of coffee there aren't 40 different vendors selling reconstructive knee surgery within a 15 mile radius.

I disagree that it's often urgent. How many times have you been to a doctor's office or hospital in your life? Of those times, how many were truly urgent? Personally, I've only had one instance when I needed medical attention right away. I could have shopped around all the other times. Even the one time when it was urgent, I might have driven a bit further if I'd known I could get a better deal somewhere else.

Two points: 1) its the emergencies that drive most of health care spending, not routine checkups, and 2) a large number of Americans do not use health care until they need it (i.e. when it is urgent).

You're also ignoring that, as a patient one will have the information necessary to comparison shop AND that there will be sufficient options for that to be necessary. Regarding the former people don't know what they need until they are told by someone else, and regarding the latter most rural communiteis have exactly one hospital option available.

“What if 30 percent of the public had Health Savings Accounts?” said Paul. “What do you do when you use your own money? You call up doctors and ask the price… if you create a real marketplace, you drive prices down.”

Haha, yeah, I'm having a heart attack right now -- better get on the phone and shop prices! :)

Oh no wait, even better, let's be proactive and shop stent prices BEFORE I have a heart attack, even though I appear to be in perfectly good condition. "Hello, yes, I would like to know the price of a stent, and also the cost to implement it. What's that you say? There are a ton of factors that could affect the final cost other than just the hardware cost of the stent?"

So many dismiss the advantages that shopping for healthcare will provide using your argument. I believe it will create competition and drive down prices. The experience of shopping for healthcare will eventually become similar to shopping for a tv. If it's not an emergency, I can check amazon, target, walmart, etc, and get the best price on my tv. If it is an emergency and I need a tv right now for super bowl weekend, then I can likely go pick one up at the local walmart and can be confident that I'm not getting gouged too much.

“What if 30 percent of the public had Health Savings Accounts?” said Paul. “What do you do when you use your own money? You call up doctors and ask the price… if you create a real marketplace, you drive prices down.”

Haha, yeah, I'm having a heart attack right now -- better get on the phone and shop prices! :)

Oh no wait, even better, let's be proactive and shop stent prices BEFORE I have a heart attack, even though I appear to be in perfectly good condition. "Hello, yes, I would like to know the price of a stent, and also the cost to implement it. What's that you say? There are a ton of factors that could affect the final cost other than just the hardware cost of the stent?"

So many dismiss the advantages that shopping for healthcare will provide using your argument. I believe it will create competition and drive down prices. The experience of shopping for healthcare will eventually become similar to shopping for a tv. If it's not an emergency, I can check amazon, target, walmart, etc, and get the best price on my tv. If it is an emergency and I need a tv right now for super bowl weekend, then I can likely go pick one up at the local walmart and can be confident that I'm not getting gouged too much.

As I explained above, this will only work if 1) you actually have access to amazon, target, walmart etc. and 2) that you know what kind of "TV" to get. In the case of healthcare, many have no options (limited services int heir area) and about all they know going in is "it hurts".

“What if 30 percent of the public had Health Savings Accounts?” said Paul. “What do you do when you use your own money? You call up doctors and ask the price… if you create a real marketplace, you drive prices down.”

Haha, yeah, I'm having a heart attack right now -- better get on the phone and shop prices! :)

Oh no wait, even better, let's be proactive and shop stent prices BEFORE I have a heart attack, even though I appear to be in perfectly good condition. "Hello, yes, I would like to know the price of a stent, and also the cost to implement it. What's that you say? There are a ton of factors that could affect the final cost other than just the hardware cost of the stent?"

So many dismiss the advantages that shopping for healthcare will provide using your argument. I believe it will create competition and drive down prices. The experience of shopping for healthcare will eventually become similar to shopping for a tv. If it's not an emergency, I can check amazon, target, walmart, etc, and get the best price on my tv. If it is an emergency and I need a tv right now for super bowl weekend, then I can likely go pick one up at the local walmart and can be confident that I'm not getting gouged too much.

As I explained above, this will only work if 1) you actually have access to amazon, target, walmart etc. and 2) that you know what kind of "TV" to get. In the case of healthcare, many have no options (limited services int heir area) and about all they know going in is "it hurts".

I've seen it work. 1) Areas that have limited options eventually get more options. My brother was a struggling Dentist in Arizona. (Too many Dentists in Arizona) He, along with another Dentist he knew, where lured to the midwest for higher pay, because of shortage of dentists there. Eventually others will follow as well and prices there will come down eventually. 2) Not knowing exactly what you need. I deal with this all the time with housing contractors. Just this week I got a bid to replace a bathroom vanity. The contractor gave me a bid knowing that on average it takes half a day to replace. In my case there were lots of unforseen problems that caused it to take a full day. I just got charged the original bid, and the contractor is fine with this, because sometimes everything goes exactly as planned and it only takes 2 hours.

“What if 30 percent of the public had Health Savings Accounts?” said Paul. “What do you do when you use your own money? You call up doctors and ask the price… if you create a real marketplace, you drive prices down.”

Haha, yeah, I'm having a heart attack right now -- better get on the phone and shop prices! :)

Oh no wait, even better, let's be proactive and shop stent prices BEFORE I have a heart attack, even though I appear to be in perfectly good condition. "Hello, yes, I would like to know the price of a stent, and also the cost to implement it. What's that you say? There are a ton of factors that could affect the final cost other than just the hardware cost of the stent?"

So many dismiss the advantages that shopping for healthcare will provide using your argument. I believe it will create competition and drive down prices. The experience of shopping for healthcare will eventually become similar to shopping for a tv. If it's not an emergency, I can check amazon, target, walmart, etc, and get the best price on my tv. If it is an emergency and I need a tv right now for super bowl weekend, then I can likely go pick one up at the local walmart and can be confident that I'm not getting gouged too much.

I doubt it because I have an HSA and therefore tried to shop around. Very few places could even access a price list.